| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,416 |
1,416 |
$64K |
| D0220 |
Intraoral - periapical first radiographic image |
3,652 |
3,628 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,647 |
1,647 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,813 |
2,686 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
309 |
150 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
693 |
693 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,189 |
1,189 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,208 |
1,208 |
$19K |
| D0330 |
Panoramic radiographic image |
362 |
362 |
$15K |
| D1120 |
Prophylaxis - child |
104 |
104 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$475.50 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$246.22 |